Provider Demographics
NPI:1548996291
Name:ALLEN, TIFFANY MARIE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 KEARNEY WAY
Mailing Address - Street 2:
Mailing Address - City:INDIAN HEAD
Mailing Address - State:MD
Mailing Address - Zip Code:20640-1582
Mailing Address - Country:US
Mailing Address - Phone:301-509-1738
Mailing Address - Fax:
Practice Address - Street 1:2670 CRAIN HWY STE 510
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2819
Practice Address - Country:US
Practice Address - Phone:301-509-1738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1548996291Medicaid